Every finding on record at Amedisys Mississippi, LLC

*EMERGENCY PREPAREDNESS* Survey conducted on 09/29-10/02/2025 revealed the above facility meets all applicable Federal, State and local emergency preparedness requirements. No violations identified.

*MERIDIAN* The Medicare Recertification survey conducted 09/29-10/02/2025 revealed the facility has met all Medicare Conditions of Participation for Home Health Facilities. However, Standard level deficiencies were identified as follows..... ______________

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on staff interview, policy and procedure review, and review of the facility report “HHA error summary by agency”, the facility failed to encode and electronically transmit each completed Outcome and Assessment Information Set (OASIS) assessment within 30 days of completing the assessment of the beneficiary 345 patients in the past 12 months 08/01/2024 to 08/01/2025. Findings Include: An interview with the Director of Operations (DOO) confirmed the facility is expected to submit OASIS data within 30 days of completing the OASIS assessment. The DOO also confirms that the facility is aware of late OASIS data submission. Review of the facility’s Internet Quality Improvement and Evaluation System (IQIES) report, “The HHA Error summary report by Agency,” dated 08/01/2024-08/01/2025, for the past 12 months revealed “Error -3330” for 345 patient assessments submitted late, after 30 days of completing the assessment of the beneficiary. Review of facility’s policy, Received and reviewed Policy for Reporting OASIS information. Policy: AA-006 Subject: Oasis Outcome and Information Set Last review date: 06/09/2025 Home Health Procedure: 5. Oasis are collected… The agency complies with Oasis data collection and submission requirements as outlined in the Condition of Participation, electronically submitting Oasis data within 30 days of completing the oasis assessment.” During the exit conference on 10/02/2025 at 12:00 p.m. with the DOO, Area Vice President of Operations, Vice President of Operations, Vice President of Rapid Response, and Vice President, the Survey findings were discussed, and no further documentation was submitted for review.

*EMERGENCY PREPAREDNESS* The Survey conducted 10/04-10/06/2022 revealed the above facility meets all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.

* MERIDIAN * The Medicare Recertification survey conducted 10/04-10/06/2022 revealed the above facility has met all Medicare Conditions of Participation for Home Health Agencies. However, Standard-level violations were identified. ___________________

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on staff interview, medical record review, and policy and procedure review the facility failed to ensure the individualized plan of care was provided to include the coordination of services and quality of care in four (4) of 12 medical records reviewed; Patients #9, #12, #15 and #16. Findings Include: During an interview on 10/04/2022 at 2:42 p.m., the Vice President Director of Operations confirmed the home health aide (HHA) is on maternity leave and HHA services are provided by the licensed practical nurse (LPN). During an interview on 10/04/2022 at 3:28 p.m., the Area Vice President of Business Development confirmed the facility's Occupational Therapist and Occupational Therapy Assistants are providing HHA services, not the LPN and further confirms that facility uses HHA services from a neighboring sister branch. Medical record review for Patient #15, reveals physician order dated 8/15/202, “…discontinue home health aide due to none available…”. Medical record review for Patient #16, reveals physician order dated 8/16/2022, “…discharge HHA visits due to HHA not available…”. Medical record review for Patient #9, reveals missed visit notification dated 9/23/2022 on Client Coordination Note Report, “…visit was not made for the following reasons…no available SN…”. Medical record review for Patient #12 reveals missed visit notification dated 9/7/2022 on Client Coordination Note Report, “…visit was not made for the following reasons…No SN available…”, and the Client Coordination Note Report dated 9/9/2022 reveals, “…visit was not made for the following reasons…No SN available…”. Review of policy and procedure titled “Plan of Care (POC)/Care Planning Process”, policy AA-014, dated 5/9/2022, revealed on page 1, “…Purpose…A plan of care will be developed through a care planning process, which is designed to provide care, treatment, and services that are appropriate to the patient’s individual needs, as well as patient’s choice. Patients receiving personal care, homemaker, and/or companion services only will have services provided in accordance with an individualized plan of care developed by the Registered Nurse…”, and further reveals on page 3, “…7. The RN, RPT, OTR, Social Worker, and SLP are responsible for care planning and coordination. The Clinical Manager is responsible for facilitating coordination among all disciplines…8. Modification to the POC will be based upon the patient’s individual condition, problems, needs, and reassessments. Modifications to the plan of care will be documented in a verbal order as obtained from the physician…”. Review of policy and procedure titled “Services Provided/Supervision of Disciplines – RN/LPN”, policy AA-007(a), dated 6/24/2021, revealed on page 1, “…Purpose...to provide, coordinate, and supervise individualized patient care services by qualified individuals for each patient in accordance with acceptable standards of nursing practice and the plan of care…”, and further reveals on page 3, “…a licensed nurse…may be assigned to perform a home health aide visit at the discretion of their supervisor as needed to support agency operations (for illness/vacation coverage/etc.)…”. During Exit Conference on 10/06/2022 at 5:45 p.m. to 6:00 p.m. survey findings was discussed, and no further documentation was submitted for review.